Enhancing Relationships and · Enhancing Communication and HIV Outcomes (ECHO) Study Aims 1. To evaluate possible racial/ethnic disparities in patient-provider communication quality;

Enhancing Relationships and

Communication in HIV Care

Mary Catherine Beach, MD, MPH

Associate Professor of Medicine

Johns Hopkins University

Baltimore, MD, United States

Disclosures

• I have been paid to develop and deliver

non-product based talks on communication

and health disparities for Merck &

Company

Overview

• What do we know about communication in

HIV care?

• How can we improve communication to

better patient outcomes?

Enhancing Communication and HIV

Outcomes (ECHO) Study Aims

1. To evaluate possible racial/ethnic disparities in

patient-provider communication quality;

2. To evaluate which aspects of communication

and relationships are associated with better

patient outcomes;

and

3. To develop and test an intervention to improve

communication quality in HIV care.

Phase 1

Observational

Phase 2

Small RCT

ECHO Study Sites







patient outcomes;

and



Phase 1

Observational

Phase 2

Small RCT







patient outcomes;

and



Phase 1

Observational

Phase 2

Small RCT

Provider Characteristics

(Attitudes)

Patient

Characteristics

Patient-Provider

Communication

Patient Experience

Of Communication

Patient

Outcomes

Conceptual Framework for Research on

Interpersonal Processes of Care and Patient Outcomes


(Attitudes)

Patient

Characteristics

Patient-Provider

Communication

Patient Experience

Of Communication

Patient

Outcomes



Independent Variable: Mindfulness-

Mindful Attention Awareness Scale*• Self-report on provider baseline questionnaire

• 14 items

• Sample items– I find myself preoccupied with the future or the past. (R)

– I find myself listening to someone with one ear, doing something else at the same time. (R)

– I forget a person’s name almost as soon as I’ve been told it for the first time. (R)

Responses: almost always – almost never

*Brown and Ryan, J Pers Soc Psychol. 84(4):822-848

Patient Evaluations of Care are Associated

with Providers’ Self-Rated MindfulnessProvider Mindfulness Tertile

Low

(n=150) Middle (n=146) High (n=141)

High Provider Communication

Score,2 n (%)

62

(41.3)67 (46.5) 79 (56.8)

OR

(95% CI)

Unadjusted — 1.43 (0.89-2.41) 2.14 (1.26-3.61)

Adjusted for covariates — 1.60 (0.94-2.71) 2.40 (1.30-4.44)

Adjusted for covariates

+ visit length— 1.55 (0.92-2.62) 2.28 (1.23-4.21)

Highest Patient Satisfaction,3 n (%)82

(54.7)91 (63.2) 95 (68.4)

OR

(95% CI)

Unadjusted — 1.71 (0.99-2.96) 2.37 (1.29-4.37)

Adjusted for covariates — 1.64 (0.89-3.02) 2.25 (1.10-4.61)

Adjusted for covariates +

visit length— 1.69 (0.91-3.12) 2.23 (1.07-4.66)

Independent Variable: Provider

Cultural Competence

• Self-report on provider baseline questionnaire

• Novel measure

• Sample items

– I always try to find out what patients think is the cause of their illness

– I feel less than competent working with patients from cultural backgrounds different from mine

Responses: Strongly disagree — strongly agree (6-point scale)

Cultural Competence and Patient Outcomes

(High/middle CC vs. low CC)

Outcome Nonwhite White

Medication

Self-Efficacy1.68 (.95-3.0) 0.50 (.18-1.4)

Adherence 2.87 (1.4-6.0) 0.12 (.01-1.3)

Viral Suppression 1.77 (1.0-3.2) 0.41 (.12-1.4)

Adjusted for site; patient age, gender, marital

status, employment; provider gender; patient-

provider race concordance

Disparities Analysis: Association of race with

outcomes by provider cultural competence

Provider CC Tertile

Non-White vs. White Odds Ratio

Outcome Low Middle/High

Medication Self-Efficacy 3.77 (1.2-11.4) 1.14 (0.6-2.2)

Adherence 6.07 (1.1-33.9) 1.63 (0.6-4.7)

Viral Suppression 13.0 (3.4-49.0) 1.20 (0.6-2.4)

Adjusted for site; patient age, gender, education,

literacy, employment, substance use, QOL; provider

race, profession (non-MD vs. MD)


(Attitudes)

Patient

Characteristics

Patient-Provider

Communication

Patient Experience

Of Communication

Patient Outcomes



Dialogue about ARV Initiation

“Prior to writing the first

prescriptions, the clinician should

assess the patient’s readiness to take

medication, factors that might limit

adherence, understanding of the

disease and the regimen, social

support, housing, work and home

situation, and daily schedules.”

No studies have directly observed

clinicians and patients communicating

about ART initiation

ART Initiation Communication

Topic Number of

Encounters

Total N=24

Percent of

Encounters

Readiness to Start 12 50%

Factors limiting adherence 3 13%

Home/work situation 1 4%

Daily schedule 1 4%

Patient understanding 0 0%

Social support 0 0%







patient outcomes;

and



Phase 1

Observational

Phase 2

Small RCT

Principles for Intervention Development

• Related to communication

• Focus on content area importance to reduction of

racial/ethnic disparities

– Patient adherence

• Focus on patient-provider dialogue about medication

adherence

• Targeted at both patients and providers

Study Design and Data Collection

Enroll 26

HIV

providers

across

3 sites

13 providers

get 1-hour

training session

13 providers

get no

training

5-10 patients per

provider are

enrolled,

interviewed,

and encounters

are audio-taped

5-10 patients per

provider are

enrolled,

coached,

interviewed,

and encounters

are audio-taped

Randomize

within site

Primary

Outcomes

Audio-recorded

measures of

patient and

provider

communication

behaviors

Communication about Therapeutic Regimen

Intervene Control p-value^

All patient therapeutic talk* 56.4 49.9 0.211

All provider therapeutic

talk* 110.6 78.0 <0.001

Ratio of provider/patient

therapeutic talk* 2.4 1.9 0.003

Any problem-solving about

adherence barriers, % 41% 22% 0.026

All values are means except where otherwise indicated

^p-values obtained using Kruskall Wallis tests

Provider Rapport-Building/ Engagement of

Patient

Intervention Control p-value^

Positive Talk 43.6 37.6 0.039

Emotional Talk 26.1 17.6 <0.001

Asks for Patient Opinion 2.9 2.0 0.009

All values are means


Patient Engagement

Intervention Control p-value^

Patient question-asking 10.9 10.9 0.965

Asks for service 0.5 0.5 0.886

Paraphrases/checks for

understanding 5.0 5.0 0.695

All values are means


What did we learn from Phase 2 of ECHO?

• A brief training improved provider

communication and increased dialogue about

medication adherence.

– However, most of the increase in adherence

dialogue was provider rather than patient talk

• Further training may be required to help

providers engage patients more effectively

Next Step: A More Extensive

Intervention

R34MH089279-01

Study Intervention

BaselineAssessment

One-Day Workshop on Motivational Interviewing

Individualized Feedback

Follow-up Assessment

Minimal

Intensive

6 months

BaselineAssessment

One-Day Workshop on Motivational Interviewing

Follow-upAssessment

Feedback Process (Intensive Arm)

Changes in Patient-Centeredness for Minimal and

Intensive Intervention Groups.9

11.

11.

21.

31.

4

(mea

n) p

tcen

t1

0 .5 1longfollow

control intervention

Intensive p=0.056

Minimal p=0.033

Intensive vs.

Minimal

p=0.930

12

34

5

(me

an

) d

isa

gre

em

ents

0 1 2timeframe


Changes in Disapproval for Minimal and

Intensive Intervention Groups

Intensive vs.

Minimal

p=0.430

Intensive p<0.001

Minimal p=0.040

Changes in Asking Patient Opinion for Minimal and

Intensive Intervention Groups2

.53

3.5

44

.55

(me

an)

ask

od

0 1 2timeframe


Intensive vs.

Minimal

p=0.035

Intensive p=0.003

Minimal p=0.641

Changes in Patient Ratings for Minimal

and Intensive Intervention Groups6

.46

.56

.66

.76

.86

.9

(me

an

) vi

sitc

limate

0 .5 1longfollow


Intensive p=0.005

Minimal p=0.032Intensive vs.

Minimal

p=0.230

Summary

• High quality communication and relationships are

associated with better patient outcomes in HIV care

• We have a pretty good idea about what ‘high quality’

communication looks like, but are learning more

• Interventions to improve communication are

effective, but the most effective and efficient ways to

do so are not perfectly clear

“I have learned that people will forget

what you said, people will forget what

you did, but people will never forget how

you made them feel.”

- Maya Angelou

Documents

Enhancing Relationships and · Enhancing Communication and HIV Outcomes (ECHO) Study Aims 1. To evaluate possible racial/ethnic disparities in patient-provider communication quality;